A systematic review and meta-analysis on the prevalence of non-malignant, organic gastrointestinal disorders misdiagnosed as irritable bowel syndrome.

Treatable gastrointestinal disorders in patients with symptoms typical for irritable bowel syndrome (IBS) may be overlooked. The prevalence of five gastrointestinal conditions-bile acid diarrhoea (BAD), carbohydrate malabsorption (CM), microscopic colitis (MC), pancreatic exocrine insufficiency (PEI) and small intestinal bacterial overgrowth (SIBO) was systematically assessed from studies including consecutive patients meeting diagnostic criteria for IBS. 4 databases were searched from 1978 to 2020. Studies were included if they evaluated the prevalence of these conditions in secondary healthcare setting. Estimated pooled rates were calculated and statistical heterogeneity between studies was evaluated using Q and I2 statistics. Seven studies (n = 597) estimated the pooled prevalence for BAD as 41% (95% CI 29-54). 17 studies (n = 5068) estimated that of MC as 3% (95% CI 2-4%). Two studies (n = 478) suggested a rate of 4.6% (range: 1.8-6.1%) for PEI. Using breath testing, 26 studies (n = 6700) and 13 studies (n = 3415) estimated the prevalence of lactose and fructose malabsorption as 54% (95% CI 44-64%) and 43% (95% CI 23-62%); 36 studies (n = 4630) and 22 studies (n = 2149) estimated that of SIBO as 49% (95% CI 40-57%) with lactulose and 19% (95% CI 13-27%) with glucose. Rates of all conditions were significantly higher than in healthy controls. A significant proportion of patients presenting to secondary care with IBS have an organic condition which may account for their symptoms. Failure to exclude such conditions will deny patients effective treatment.

Effects of Proton Pump Inhibitors on the Small Bowel and Stool Microbiomes.

BACKGROUND: Proton pump inhibitor (PPI) use is extremely common. PPIs have been suggested to affect the gut microbiome, and increase risks of Clostridium difficile infection and small intestinal bacterial overgrowth (SIBO). However, existing data are based on stool analyses and PPIs act on the foregut. AIMS: To compare the duodenal and stool microbiomes in PPI and non-PPI users. METHODS: Consecutive subjects presenting for upper endoscopy without colonoscopy were recruited. Current antibiotic users were excluded. Subjects taking PPI were age- and gender-matched 1:2 to non-PPI controls. Subjects completed medical history questionnaires, and duodenal aspirates were collected using a validated protected catheter. A subset also provided stool samples. Duodenal and stool microbiomes were analyzed by 16S rRNA sequencing. RESULTS: The duodenal microbiome exhibited no phylum-level differences between PPI (N = 59) and non-PPI subjects (N = 118), but demonstrated significantly higher relative abundances of families Campylobacteraceae (3.13-fold, FDR P value < 0.01) and Bifidobacteriaceae (2.9-fold, FDR P value < 0.01), and lower relative abundance of Clostridiaceae (88.24-fold, FDR P value < 0.0001), in PPI subjects. SIBO rates were not significantly different between groups, whether defined by culture (> 103 CFU/ml) or 16S sequencing, nor between subjects taking different PPIs. The stool microbiome exhibited significantly higher abundance of family Streptococcaceae (2.14-fold, P = 0.003), and lower Clostridiaceae (2.60-fold, FDR P value = 8.61E-13), in PPI (N = 22) versus non-PPI (N = 47) subjects. CONCLUSIONS: These findings suggest that PPI use is not associated with higher rates of SIBO. Relative abundance of Clostridiaceae was reduced in both the duodenal and stool microbiomes, and Streptococcaceae was increased in stool. The clinical implications of these findings are unknown.

Diagnosing Small Intestinal Bacterial Overgrowth: A Comparison of Lactulose Breath Tests to Small Bowel Aspirates.

BACKGROUND: Duodenal aspiration (DA) and lactulose breath tests (LBT) are commonly performed to diagnose small intestinal bacterial overgrowth (SIBO). There are no data directly comparing these tests. AIMS: To investigate the agreement between DA and LBT for the diagnosis of SIBO. METHODS: A retrospective cohort study of adult patients who underwent a LBT and a DA at a tertiary care center over 9 years was assembled. LBT was considered positive if the hydrogen baseline or peak change measurement was ≥ 20 ppm, and/or if the methane baseline or peak change was ≥ 10 ppm. DA was considered positive if > 100,000 cfu/mL of gram-negative flora was identified on culture, and contaminated if > 100,000 cfu/mL of gram-positive flora was identified. RESULTS: A total of 106 patients were evaluated; 81 (76.4%) were female; the mean age was 53.4 ± 15.9 years. 21 patients (19.8%) had evidence of contamination on DA. 14 (16.5%) patients had a positive DA result. Patients with diabetes mellitus and those with PPI use were more likely to have a positive DA (94.4% vs. 71.4%, p = 0.007; 62% vs. 28.6%, p = 0.021, respectively). 33 (31.1%) patients had a positive LBT. Patients with a history of small bowel resection were more likely to have a positive LBT (12.1% vs. 1.4%, p = 0.016). DA and LBT results agreed in 54 patients (63.5%; kappa = - 0.02), indicating poor agreement. CONCLUSIONS: The agreement between LBT and DA in evaluation for SIBO was poor. LBT may be favorable to DA, as LBT is safer, cheaper, and less likely to yield a contaminant result.

The overlap between irritable bowel syndrome and organic gastrointestinal diseases.

Irritable bowel syndrome (IBS) is a common functional bowel disorder characterised by symptoms of recurrent abdominal pain associated with a change in bowel habit. This condition is one of the most frequent reasons to seek a gastroenterology consultation in primary and secondary care. The diagnosis of IBS is made by identifying characteristic symptoms, as defined by the Rome criteria, and excluding organic gastrointestinal diseases that might otherwise explain these symptoms. Organic conditions that can be mistaken for IBS include coeliac disease, inflammatory bowel disease (IBD), colorectal cancer, and, in those with diarrhoea-predominant symptoms, chronic gastrointestinal infections, microscopic colitis, and primary bile acid diarrhoea. The concept of small intestinal bacterial overgrowth being associated with IBS is shrouded with controversy and uncertainty, mainly because of invalid tests due to poor sensitivity and specificity, potentially leading to incorrect assumptions. There is insufficient evidence to link IBS-type symptoms with exocrine pancreatic insufficiency or with symptomatic uncomplicated diverticular disease, since both are hampered by conflicting data. Finally, there is growing appreciation that IBS can present in patients with known but stable organic gastrointestinal diseases, such as quiescent IBD or coeliac disease. Recognising functional gut symptoms in these individuals is paramount so that potentially harmful escalations in immunosuppressive therapy can be avoided and attention can be focused on addressing disorders of gut-brain interaction. This Review endeavours to aid clinicians who practise adult gastroenterology in recognising the potential overlap between IBS and organic gastrointestinal diseases and highlights areas in need of further research and clarity.

Acute gastric injury after ingestion of substrate with hyperosmolar glucose and benzoate inversely related with small intestinal bacterial overgrowth.

BACKGROUND/AIMS: The occurrence of gastrointestinal symptoms and the presence of small intestinal bacterial overgrowth (SIBO) could be determined after ingestion of substrate with highly concentrated glucose for glucose breath test (GBT), after which endoscopic images for acute gastric injury have not been clarified. The aims of this study were to investigate the prevalence and relationship of acute gastric injury with SIBO after GBT. MATERIALS AND METHODS: A cohort of 235 patients with functional gastrointestinal symptoms undergoing breath test with 50 g glucose solution, immediately followed by upper endoscopy were surveyed. The acute gastric injury in endoscopic images and the GBT for hydrogen (H2) or methane (CH4) were assessed. RESULTS: The prevalence of acute gastric injury was 28.1% (66/235) after GBT. There were significant differences in GBT positivity (+) with and without gastric injury (25.8% vs 40.8%, p=0.03). In subtypes, GBT (H2) + was significantly lower in group with gastric injury than in the group without. No differences were seen in GBT (CH4) + between two groups. On multivariate analysis, the subtype of GBT (H2) + (Odds ratio (OR)=0.42; 95% Confidence interval (CI)=0.20-0.90; p=0.03) inversely and female (OR=2.11; 95% CI=1.11-4.00; p=0.02) were significantly related with gastric injury. Whereas gastric injury was the only independent related factor for GBT + inversely (OR=0.51; 95% CI=0.27-0.97; p=0.04). CONCLUSION: Highly concentrated glucose might provoke acute gastric injury, which could predict the absence of SIBO.

Vague abdominal pain after Roux-en-Y gastric bypass: not always an internal herniation: case report and literature review.

Background: Roux-en-Y gastric bypass is a frequently carried out bariatric procedure, proven to be effective in the management of obesity and its accompanying health issues. Following its popularity, admission to the emergency department for abdominal pain is often seen with known early and late onset causes. We present a case of a young woman with vague abdominal pain years after her gastric bypass, who eventually underwent a resection of a 'candy cane' like biliopancreatic blind loop.Methods: A healthy 23-year-old woman has been suffering of vague abdominal complaints after a gastric bypass procedure 4 years earlier. Postprandial pain, diarrhoea and abdominal distension were present at a daily to weekly basis. Several investigations and management options were administered by surgeons, gastroenterologists as well as endocrinologists. On a performed explorative laparoscopy, a large blind loop at the entero-enteric anastomosis was seen and resected.Results: At current follow-up of 15 months the resection of the candy cane like blind end of the biliopancreatic loop resulted in a complete withdrawal of our patient's symptoms. A tentative diagnosis of bacterial overgrowth in the blind loop was made.Conclusions: Abdominal pain after gastric bypass is a frequent cause of admission to the emergency department. Besides the more serious complications, internal hernia is often withheld as possible diagnosis in the differential diagnosis of late onset, postprandial epigastric pain. This case report highlights another possibility. At initial surgery, a candy cane shaped blind loop should be avoided both at the gastro-jejunal as well as the entero-enteric anastomosis.

Systematic review with meta-analysis: the prevalence of small intestinal bacterial overgrowth in inflammatory bowel disease.

BACKGROUND: Current data on small intestinal bacterial overgrowth (SIBO) in patients with inflammatory bowel diseases (IBD) are controversial. AIM: To conduct a systematic review and meta-analysis to determine the prevalence of SIBO in patients with ulcerative colitis (UC) and Crohn's disease (CD). METHODS: Electronic databases were searched up to May 2018 for studies reporting prevalence of SIBO in IBD patients. The prevalence rate of SIBO among IBD patients and the odds ratio (OR) and 95% CI of SIBO in IBD patients compared with controls were calculated. RESULTS: The final dataset included 11 studies (1175 adult patients with IBD and 407 controls), all utilising breath test for diagnosis of SIBO. The proportion of SIBO in IBD patients was 22.3% (95% CI 19.92-24.68). The OR for SIBO in IBD patients was 9.51 (95% CI 3.39-26.68) compared to non-IBD controls, and high in both CD (OR = 10.86; 95% CI 2.76-42.69) and UC (OR = 7.96; 95% CI 1.66-38.35). In patients with CD, subgroup analysis showed the presence of fibrostenosing disease (OR = 7.47; 95% CI 2.51-22.20) and prior bowel surgery (OR = 2.38; 95% CI 1.65-3.44), especially resection of the ileocecal valve, increased the odds of SIBO. Individual studies suggest that combined small and large bowel disease but not disease activity may be associated with SIBO. CONCLUSIONS: Overall, there is a substantial increase in the prevalence of SIBO in IBD patients compared to controls. Prior surgery and the presence of fibrostenosing disease are risk factors for SIBO in IBD.

Fecal microbiota analysis of children with small intestinal bacterial overgrowth among residents of an urban slum in Brazil / Análise da microbiota fecal de crianças com sobrecrescimento bacteriano no intestino delgado de moradoras de uma favela urbana no Brasil

Abstract Objective: To analyze the fecal microbiota composition of children living in an urban slum in Brazil, with or without small intestinal bacterial overgrowth, and to investigate the occurrence of stunting and anemia. Methods: A total of 100 children were studied, aged 5-11 years, from the municipality of Osasco, São Paulo. Small intestinal bacterial overgrowth was screened through hydrogen and methane breath test with lactulose. Weight and height were measured, and the height-for-age and body mass-for-age anthropometric indexes were calculated. The occurrence of anemia was investigated by capillary hemoglobin. Analysis of bacterial phylum, genus, and species was performed by real-time polymerase chain reaction in fecal samples. Results: Small intestinal bacterial overgrowth was identified in 61.0% of the children. A lower mean of height-for-age Z-score ([−0.48 ± 0.90] vs. [−0.11 ± 0.97]; p = 0.027), as well as capillary hemoglobin ([12.61 ± 1.03 g/dL] vs. [13.44 ± 1.19 g/dL]; p < 0.001) was demonstrated in children with SIBO when compared with children without small intestinal bacterial overgrowth. Children with small intestinal bacterial overgrowth presented a higher frequency of Salmonella spp., when compared to those without small intestinal bacterial overgrowth (37.7% vs. 10.3%; p = 0.002). Higher counts of total Eubacteria (p = 0.014) and Firmicutes (p = 0.038) were observed in children without small intestinal bacterial overgrowth; however, a higher count of Salmonella (p = 0.002) was found in children with small intestinal bacterial overgrowth. Conclusion: Children who lived in a slum and were diagnosed with small intestinal bacterial overgrowth showed lower H/A Z-scores and hemoglobin levels. Furthermore, differences were observed in the fecal microbiota of children with small intestinal bacterial overgrowth, when compared to those without it; specifically, a higher frequency and count of Salmonella, and lower counts of Firmicutes and total Eubacteria.

Resumo Objetivo: Analisar a composição da microbiota fecal de crianças moradoras de uma favela urbana no Brasil, com e sem sobrecrescimento bacteriano no intestino delgado, e investigar a ocorrência de déficit de crescimento e anemia. Métodos: Foram estudadas 100 crianças, com idade entre 5 e 11 anos, na cidade de Osasco, São Paulo. Sobrecrescimento bacteriano no intestino delgado foi pesquisado por teste respiratório do hidrogênio e metano no ar expirado com lactulose. Foram mensurados peso, estatura e calculados os índices antropométricos estatura para idade e índice de massa corporal para idade. Foi investigada a ocorrência de anemia, pela avaliação da hemoglobina capilar. A análise dos filos, gêneros e espécies bacterianas em amostras de fezes foi realizada por polymerase chain reaction em tempo real. Resultados: Sobrecrescimento bacteriano no intestino delgado foi diagnosticado em 61,0% das crianças avaliadas. Foi verificada menor média do escore Z do índice estatura para idade (-0,48±0,90 vs.-0,11±0,97 DP) e de hemoglobina capilar (12,61±1,03 vs. 13,44±1,19 g/dL) no grupo de crianças com sobrecrescimento bacteriano no intestino delgado, quando comparadas àquelas sem sobrecrescimento bacteriano no intestino delgado (p < 0,05). Nas crianças com sobrecrescimento bacteriano no intestino delgado foi observada maior frequência de Salmonella spp., quando comparadas àquelas sem sobrecrescimento bacteriano no intestino delgado (37,7% vs. 10,3%; p = 0,002). Maior contagem de Eubactérias totais (p = 0,014) e Firmicutes (p = 0,038) foi observada nas crianças sem sobrecrescimento bacteriano no intestino delgado, enquanto que as crianças com sobrecrescimento bacteriano no intestino delgado apresentaram maior contagem de Salmonella (p = 0,002). Conclusão: Nas crianças com diagnóstico de sobrecrescimento bacteriano no intestino delgado verificaram-se menores valores de estatura para idade e de hemoglobina. Foram constatadas diferenças na microbiota fecal das crianças com sobrecrescimento bacteriano no intestino delgado, especificamente, maior frequência e contagem de Salmonella spp. e menores contagens de Firmicutes e Eubactérias totais.

Celiac Disease and Other Causes of Duodenitis.

CONTEXT: - Patients who receive an upper gastrointestinal endoscopic examination frequently have biopsies taken from the duodenum. Accurate interpretation of duodenal biopsies is essential for patient care. Celiac disease is a common clinical concern, but pathologists need to be aware of other conditions of the duodenum that mimic celiac disease. OBJECTIVE: - To review the normal histologic features of duodenal mucosa and describe the clinical and histologic findings in celiac disease and its mimics, listing the differentiating features of biopsies with villous atrophy and epithelial lymphocytosis. DATA SOURCES: - The study comprises a literature review of pertinent publications as of November 30, 2016. CONCLUSIONS: - Celiac disease is a common cause of abnormal duodenal histology. However, many of the histologic features found in the duodenal biopsy of patients with celiac disease are also present in other conditions that affect the small bowel. Diagnostic precision may be enhanced by obtaining a careful patient history and by ancillary laboratory testing, particularly for the presence of antitissue transglutaminase antibodies.

Small-Intestinal Bacterial Overgrowth is Associated With Concurrent Intestinal Inflammation But Not With Systemic Inflammation in Crohn's Disease Patients.

GOALS: We studied the prevalence and predictors of small-intestinal bacterial overgrowth (SIBO) in Crohn's disease (CD) outpatients and the relationship between SIBO and intestinal and/or systemic inflammation. BACKGROUND: The relationship of SIBO with systemic and intestinal inflammation in CD patients is unclear. STUDY: In this cross-sectional study, conducted between June, 2013 and January, 2015, 92 CD patients and 97 controls with nonchronic gastrointestinal complaints were assessed for the presence of SIBO using the H2/CH4 glucose breath test. Multivariate logistic regression was performed to investigate the potential association between SIBO and demographic, disease-related data, systemic markers of inflammation (C-reactive protein, and erythrocyte sedimentation rate), and biomarker of intestinal inflammation [fecal calprotectin concentration (FCC)]. RESULTS: The SIBO rate was significantly higher in CD patients than in controls (32.6% vs. 12.4%, respectively, P=0.0008). Patients with and without SIBO were comparable with regard to demographics, systemic inflammatory biomarkers, and disease characteristics, except for the stricturing phenotype being more common in SIBO-positive CD patients (43.3% vs. 19.3%, P=0.015). Notably, FCC was significantly higher in SIBO-positive patients (median of 485.8 vs.132.7 µg/g; P=0.004). Patients presenting increased FCC and stricturing disease had an odds of 9.43 (95% confidence interval, 3.04-11.31; P<0.0001) and 3.83 (95% confidence interval, 1.54-6.75; P=0.025) respectively, for SIBO diagnosis. CONCLUSIONS: In CD patients, SIBO is a highly prevalent condition. Stricturing phenotype and increased FCC were strongly and independently associated with the presence of SIBO. SIBO diagnostic work-up followed by directed treatment is recommended in CD patients who present stricturing disease, especially in those with concurrent intestinal inflammation.

Clinical decision-making in managing changes in gastrointestinal function following cancer therapies: Is experience enough?

In patients with gastrointestinal (GI) disorders, identical symptoms may occur for many different reasons. This prospective study assessed whether experienced clinicians can predict accurately the underlying diagnosis or diagnoses contributing to specific symptoms based on the history and physical examination. Three clinicians assessed 47 patients referred for management of troublesome GI symptoms identified after treatment for cancer. Investigations were requested following our comprehensive, peer-reviewed algorithm. The clinicians then recorded their predictions as to the results of those investigations. After each patient had completed all their investigations, had received optimal management and had been discharged from the clinic, the predicted diagnoses were compared to those made. The clinicians predicted 92 diagnoses (1.9 per patient). After investigation, a total of 168 unique diagnoses were identified (3.5 per patient). Of the 92 predicted diagnoses, 41 (43%) matched the diagnosis. Of the 168 actual diagnoses identified, only 24% matched the prediction. None of the clinicians predicted the correct combination of diagnoses contributing to bowel symptoms. Clinical acumen alone is inadequate at determining cause for symptoms in patients with GI symptoms developing after cancer therapy.

Prevalence of small intestine bacterial overgrowth in patients with gastrointestinal symptoms / Prevalência de supercrescimento bacteriano do intestino delgado em pacientes com sintomas intestinais funcionais

ABSTRACT BACKGROUND Small intestine bacterial overgrowth is a heterogeneous syndrome characterized by an increase in the number and/or the presence of atypical microbiota in the small intestine. The symptoms of small intestine bacterial overgrowth are unspecific, encompassing abdominal pain/distension, diarrhea and flatulence. Due to the increased cost and complexity for carrying out the jejunal aspirate, the gold standard for diagnosis of the syndrome, routinely the hydrogen (H 2 ) breath test has been used, utilizing glucose or lactulose as substrate, which is able to determine, in the exhaled air, the H 2 concentration produced from the intestinal bacterial metabolism. However, due to a number of individuals presenting a methanogenic microbiota, which does not produce H 2 , the testing on devices capable of detecting, concurrently, the concentration of exhaled H 2 and methane (CH 4 ) is justified. OBJECTIVE This study aimed to determine the prevalence of small intestine bacterial overgrowth in patients with digestive symptoms, through a comparative analysis of breath tests of H 2 or H 2 and CH 4 associated, using glucose as substrate . METHODS A total of 200 patients of both sexes without age limitation were evaluated, being directed to a Breath Test Laboratory for performing the H 2 test (100 patients) and of exhaled H 2 and CH 4 (100 patients) due to gastrointestinal complaints, most of them patients with gastrointestinal functional disorders. RESULTS The results indicated a significant prevalence of small intestine bacterial overgrowth in the H 2 test and in the test of exhaled H 2 and CH 4 (56% and 64% respectively) in patients with gastrointestinal symptoms, and higher prevalence in females. It found further that methane gas was alone responsible for positivity in 18% of patients. CONCLUSION The data found in this study is consistent with the findings of the current literature and underscores the need for using devices capable of capturing the two gases (exhaled H 2 and CH 4 ) to improve the sensitivity and hence the accuracy of small intestine bacterial overgrowth diagnosis in daily medical practice.

RESUMO CONTEXTO O supercrescimento bacteriano do intestino delgado é uma síndrome heterogênea, caracterizada pelo aumento no número e/ou presença de uma microbiota atípica no intestino delgado. Os sintomas do supercrescimento bacteriano do intestino delgado são inespecíficos englobando quadro de dor/distensão abdominal, diarreia e flatulência. Devido ao maior custo e complexidade para a realização do aspirado jejunal, padrão ouro para o diagnóstico da síndrome, tem sido utilizado rotineiramente o teste do hidrogênio (H 2 ) expirado, utilizando glicose ou lactulose como substrato, que é capaz de determinar, no ar expirado, a concentração de H 2 produzida a partir do metabolismo bacteriano intestinal. Entretanto, em decorrência de uma parcela de indivíduos apresentar uma microbiota metanogênica, não produtora de H 2 , justifica-se a realização do teste em aparelhos capazes de detectar, concomitantemente, a concentração de H 2 e metano (CH 4 ) expirados. OBJETIVO O presente estudo teve como objetivo determinar a prevalência de supercrescimento bacteriano do intestino delgado em pacientes com sintomas digestivos, através de uma análise comparativa dos testes respiratórios empregando H 2 ou H 2 e CH 4 associados, utilizando a glicose como substrato. MÉTODOS Foram avaliados 200 pacientes de ambos os sexos, sem limitação de idade, encaminhados a um Laboratório de Teste Respiratório para realização do teste de H 2 (100 pacientes) e de H 2 e CH 4 expirados (100 pacientes) devido a queixas gastrointestinais, a maioria deles portadores de distúrbios funcionais gastrointestinais. RESULTADOS Os resultados obtidos indicaram uma significativa prevalência do supercrescimento bacteriano do intestino delgado no teste do H 2 e no teste do H 2 e CH 4 expirados (56% e 64%, respectivamente) em pacientes com sintomas gastrointestinais, além de maior predominância no sexo feminino. Constatou-se ainda, que o gás metano foi isoladamente responsável pela positividade em 18% do total de pacientes. CONCLUSÃO Os dados encontrados no presente estudo demonstram condizentes com os achados da literatura atual e reforçam a necessidade da utilização de aparelhos capazes de captar os dois gases (H 2 e CH 4 expirados) para melhorar a sensibilidade e, consequentemente, a acurácia do diagnóstico de supercrescimento bacteriano do intestino delgado na prática médica diária.

Small Intestinal Bacterial Overgrowth and Irritable Bowel Syndrome: A Bridge between Functional Organic Dichotomy.

The pathogenesis of irritable bowel syndrome (IBS), once thought to be largely psychogenic in origin, is now understood to be multifactorial. One of the reasons for this paradigm shift is the realization that gut dysbiosis, including small intestinal bacterial overgrowth (SIBO), causes IBS symptoms. Between 4% and 78% of patients with IBS and 1% and 40% of controls have SIBO; such wide variations in prevalence might result from population differences, IBS diagnostic criteria, and, most importantly, methods to diagnose SIBO. Although quantitative jejunal aspirate culture is considered the gold standard for the diagnosis of SIBO, noninvasive hydrogen breath tests have been popular. Although the glucose hydrogen breath test is highly specific, its sensitivity is low; in contrast, the early-peak criteria in the lactulose hydrogen breath test are highly nonspecific. Female gender, older age, diarrhea-predominant IBS, bloating and flatulence, proton pump inhibitor and narcotic intake, and low hemoglobin are associated with SIBO among IBS patients. Several therapeutic trials targeting gut microbes using antibiotics and probiotics have further demonstrated that not all symptoms in patients with IBS originate in the brain but rather in the gut, providing support for the micro-organic basis of IBS. A recent proof-of-concept study showing the high frequency of symptom improvement in patients with IBS with SIBO further supports this hypothesis.

Etiopathogenesis of rosacea: a prospective study with a three-year follow-up.

BACKGROUND: The aim of this study was to investigate the role of Demodex folliculorum (DF), Helicobacter pylori (HP), and small intestine bacterial overgrowth (SIBO) in the development of rosacea. METHODS: A case-control study including 60 patients with rosacea and 40 healthy controls was performed. All the patients underwent standardized skin surface biopsy to investigate DF, urea breath test for HP and lactulose breath test and glucose breath test for SIBO. Etiological therapy was started in the following order: acaricidal treatment, antibiotics for SIBO and HP. These exams were repeated after 3 years. Statistical analysis was performed. RESULTS: As regards the 88 patients who completed the entire follow-up, DF positivity was found in 47.7% of the patients, SIBO in 25.0%, and HP in 21.6%. SIBO significantly prevailed in papulopustular rosacea, while HP in erythrosis. At the 6-month follow up, the 61% of patients were in remission. After 3 years, 18% of patients dropped out, while the remaining patients repeated all the investigations. The majority of patients were still in remission and negative for HP while only 5 were positive for DF and 4 for SIBO. CONCLUSIONS: SIBO was the most relevant factor in papulopustular rosacea. Its treatment was crucial in improvement and in maintaining the clinical remission.

Positive Glucose Breath Tests in Patients with Hysterectomy, Gastrectomy, and Cholecystectomy.

BACKGROUND/AIMS: This study aimed to investigate the prevalence and characteristics of small intestinal bacterial overgrowth (SIBO) in patients undergoing abdominal surgeries, such as gastrectomy, cholecystectomy, and hysterectomy. METHODS: One hundred seventy-one patients with surgery (50 hysterectomy, 14 gastrectomy, and 107 cholecystectomy), 665 patients with functional gastrointestinal disease (FGID) and 30 healthy controls undergoing a hydrogen (H2)-methane (CH4) glucose breath test (GBT) were reviewed. RESULTS: GBT positivity (+) was significantly different among the surgical patients (43.9%), FGID patients (31.9%), and controls (13.3%) (p<0.01). With respect to the patients, 65 (38.0%), four (2.3%), and six (3.5%) surgical patients and 150 (22.6%), 30 (4.5%), and 32 (4.8%) FGID patients were in the GBT (H2)+, (CH4)+ and (mixed)+ groups, respectively (p<0.01). The gastrectomy group had a significantly increased preference in GBT+ (71.4% vs 42.0% or 41.1%, respectively) and GBT (H2)+ (64.3% vs 32.0% or 37.4%, respectively) compared with the hysterectomy or cholecystectomy groups (p<0.01). During GBT, the total H2 was significantly increased in the gastrectomy group compared with the other groups. CONCLUSIONS: SIBO producing H2 is common in abdominal surgical patients. Different features for GBT+ may be a result of the types of abdominal surgery.

Small intestinal bacterial overgrowth in adult patients with type 1 diabetes: its prevalence and relationship with metabolic control and the presence of chronic complications of the disease.

INTRODUCTION Gastrointestinal symptoms may occur in 50% to 70% of patients with diabetes. OBJECTIVES The aim of this study was to evaluate the prevalence of small intestinal bacterial overgrowth (SIBO) in patients with diabetes, as well as the relationship between SIBO and metabolic control of diabetes and the presence of chronic complications of the disease. PATIENTS AND METHODS The study group included 148 patients with type 1 diabetes, treated in the years 2013-2015. The control group consisted of 41 healthy volunteers. The presence of SIBO was assessed with a noninvasive breath test using 20 g of lactulose suspended in 200 ml of water, with the assessment of exhaled hydrogen concentrations. The measurements were performed at 15-minute intervals in the first hour and at 30-minute intervals in the second hour of the test. A positive result was considered as the output value of exhaled hydrogen of 20 parts per million (ppm) or higher or an increase in the output value of the exhaled hydrogen of 12 ppm during the first 60 minutes of the test.  RESULTS We observed a lower prevalence of SIBO in the study group in comparison with controls (56 patients [37.8%] vs 30 healthy volunteers [73%]; P = 0.006). In the logistic regression model, this association was independent of age, sex, body mass index, cigarette smoking, serum C-reactive protein concentrations, and estimated glomerular filtration rate (odds ratio, 0.26; 95% confidence interval, 0.10-0.68; P = 0.006). CONCLUSIONS The prevalence of SIBO in patients with type 1 diabetes is lower than that in healthy subjects. One of the possible causes might be the beneficial effect of nutritional therapy in patients with diabetes.

Scintigraphy Demonstrates High Rate of False-positive Results From Glucose Breath Tests for Small Bowel Bacterial Overgrowth.

BACKGROUND & AIMS: Breath tests for hydrogen and/or methane are used to detect small bowel bacterial overgrowth (SBBO), but false-positive results can arise from clinical conditions that accelerate small bowel transit and deliver unabsorbed glucose to the colon. We investigated the prevalence of false-positive results from glucose breath tests by also evaluating patients with scintigraphy. METHODS: In a retrospective study, we reviewed data from glucose breath tests performed with concurrent scintigraphy on 139 patients with suspected SBBO at the Medical College of Wisconsin from January 2003 through July 2013. Results from breath tests were considered abnormal (positive) if there was an increasing curve of hydrogen or methane by >15 parts per million above baseline within 90 minutes. Scintigraphy was used to determine whether this increase occurred before or after the glucose bolus arrived at the cecum. Data from a subset of 45 patients with prior upper gastrointestinal surgery were analyzed separately. RESULTS: Forty-six of the patients (33%) had abnormal results from breath tests. On the basis of scintigraphy findings, 22 of these patients (48%) had false-positive results, which were caused by colon fermentation of unabsorbed glucose. Colon fermentation caused false-positive results in 65% of patients who had undergone upper gastrointestinal surgery and 13% of patients without prior surgery. Patients with false-positive results caused by colonic fermentation had shorter mean oro-cecal transit times (18 minutes) compared with patients with positive breath-test results because of SBBO (79 minutes) or negative results (86 minutes). CONCLUSIONS: Almost half of positive results from glucose breath tests are false because of colonic fermentation. All patients with abnormal results from breath tests should be considered for confirmatory repeat breath testing with concurrent scintigraphy to distinguish SBBO from colonic fermentation. Most patients who have undergone upper gastrointestinal surgery have abnormal results from breath tests and should be assessed by using concurrent scintigraphy with the initial breath test.

Small intestinal bacterial overgrowth in patients with chronic pancreatitis.

GOALS: To assess the prevalence of small intestinal bacterial overgrowth (SIBO) in chronic pancreatitis (CP), and analyze factors related with SIBO in CP. BACKGROUND: SIBO is to be considered a factor that worsens symptoms and nutritional status in patients with CP. However, the few studies evaluating the rate of SIBO in CP patients used nonuniform and nonstandardized procedures, and reported a wide range of positivity (0% to 92%). Those studies often investigated CP patients with previous resection surgery (cause of SIBO per se). STUDY: CP patients and controls evaluated for SIBO by the H2 glucose breath test with a standard protocol. For CP patients, the relationship between test results, abdominal symptoms, and clinical and biochemical variables was analyzed. RESULTS: A total of 43 CP patients and 43 controls were enrolled. Of the CP patients, 8 had advanced disease (defined by M-ANNHEIM index) and none had undergone previous surgery. The glucose breath test positivity rate was higher in the CP patients than in the controls (21% vs. 14%), albeit without a significant difference (P=0.57). Mean fasting H2 excretion and mean H2 excretion at 120 minutes also had a trend toward higher levels in CP patients. There were no clinical differences between CP patients with or without SIBO, but there were nutritional differences for lower levels of vitamin D and higher levels of folate in these patients with SIBO. CONCLUSIONS: Our findings suggest that SIBO is not uncommon in uncomplicated CP patients. The lack of a significant difference compared with controls might be due to the study being underpowered. SIBO in CP patients does not seem to be related to peculiar clinical features, but it might affect nutritional status.

Increasing duodenal intraepithelial lymphocytosis found at upper endoscopy: time trends and associations.

BACKGROUND: Increased intraepithelial lymphocytosis (IEL) with preserved villous architecture is a common yet nonspecific finding on duodenal biopsies. OBJECTIVE: To study the change in frequency of isolated IEL on duodenal biopsy over time and determine whether previously reported disease associations have changed during that period. DESIGN: Retrospective study. SETTING: Single tertiary-care referral center. PATIENTS: Adults with a duodenal biopsy that showed normal villi and increased number of intraepithelial lymphocytes. INTERVENTION: Duodenal biopsy. Comprehensive electronic medical record search from January 1, 2000 through December 31, 2010. MAIN OUTCOME MEASUREMENTS: Demographic and clinical information. RESULTS: Of the 15,839 duodenal biopsies performed during the study period, 1105 (7.0%) had the histologic finding of interest. The odds of finding newly diagnosed celiac disease (CD) decreased by 0.9 on average during each year, whereas the odds of finding a non-celiac association increased by 1.12 times each year. Isolated increased IEL attributed to nonsteroidal anti-inflammatory drug (NSAID) use and small-intestine bacterial overgrowth (SIBO) increased by 1.06 and 1.3 times, respectively, for each year on average. LIMITATIONS: Retrospective design, single center. CONCLUSION: During the years 2000 through 2010, there has been an increased frequency with which duodenal biopsies were noted to have isolated increased IEL. The odds of a diagnosis of CD accounting for this finding have been decreasing, whereas the odds of NSAID use and SIBO have been increasing. Although the finding of isolated increased IEL on duodenal biopsy warrants work-up for CD in all patients, further investigation for other possible causes, including NSAID use and SIBO, should be considered as well.

Etiología de la diarrea crónica en el adulto mayor del Hospital Edgardo Rebagliati - Lima-Perú: estudio retrospectivo 2005-2011 / Etiology of chronic diarrhea in the elderly in Hospital Edgardo Rebagliati, Lima-Peru

INTRODUCCION: El impacto de la diarrea crónica en el adulto mayor es desproporcionado por diversos factores provocando mayor morbilidad y mortalidad. OBJETIVO: Describir las principales características acerca de la diarrea crónica en los pacientes ancianos del hospital Nacional Edgardo Rebagliati (Lima-Perú) durante el periodo enero del 2005 a diciembre del 2011, METODO: Estudio descriptivo y retrospectivo en la cual se revisaron las historias clínicas de los pacientes adultos mayores con el diagnostico de diarrea crónica, vertiéndose los datos en una ficha de recolección. RESULTADOS: Se revisaron las historias clínicas de 202 pacientes. La edad media fue de 73,5±6,7 años, siendo la mayoría mujeres (57.43%). Las principales comorbilidades fueron las cardiovasculares (60,4%) y endocrinas (27,2%). El tiempo de enfermedad medio fue de 21.6 ± 13.6 semanas. Los exámenes más solicitados fueron hemograma, bioquímica (glucosa, urea y creatinina), albumina, coprofuncional, parasitologico y colonoscopia. El tipo de diarrea más frecuente fue organica (84,16%). Dentro de las principales causas se encontró a la colitis microscópica (35,15%), parasitosis (15,84%), síndrome de intestino irritable (14,85%) y sobrecrecimiento bacteriano (8,42%). CONCLUSIONES: Las causas más frecuentes de diarrea crónica en el anciano son colitis microscópica, parasitosis, síndrome de intestino irritable y sobrecrecimiento bacteriano.

INTRODUCTION: The impact of chronic diarrhea in the elderly is disproportionate by several factors causing increased morbidity and mortality. OBJECTIVE: To describe the main features about the chronic diarrhea in elderly patients from Edgardo Rebagliati Hospital (Lima-Peru) during the period January 2005 to December 2011, METHOD: A descriptive and retrospective study in which we reviewed the medical records of elderly patients with the diagnosis of chronic diarrhea, pouring in a data collection sheet. RESULTS: We reviewed the medical records of 202 patients. The mean age was 73.5 ± 6.7 years, with most women (57.43%). Major comorbidities were cardiovascular (60.4%) and endocrine (27.2%). The half time of illness was 21.6 ± 13.6 weeks. The most requested tests were CBC, biochemistry, albumin, coprofuncional, parasitological and colonoscopy. The most common type of diarrhea was the organic (84.16%). Among the main causes were found microscopic colitis (35.15%), parasites (15.84%), irritable bowel syndrome (14.85%) and bacterial overgrowth (8.42%). CONCLUSIONS: The most common causes of chronic diarrhea in the elderly are microscopic colitis, parasites, irritable bowel syndrome and bacterial overgrowth.